Provider Demographics
NPI:1821024233
Name:VAN AMERONGEN, RYAN TOBIAS (MA, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:TOBIAS
Last Name:VAN AMERONGEN
Suffix:
Gender:M
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:TOBY
Other - Middle Name:
Other - Last Name:VAN AMERONGEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, ATC, LAT
Mailing Address - Street 1:307 E E ST
Mailing Address - Street 2:APT: 10
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2661
Mailing Address - Country:US
Mailing Address - Phone:208-885-0225
Mailing Address - Fax:208-885-0254
Practice Address - Street 1:875 PERIMETER DR
Practice Address - Street 2:MS:2302
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-2302
Practice Address - Country:US
Practice Address - Phone:208-885-0225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer